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1.
Circulation ; 140(18): 1463-1476, 2019 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-31524498

RESUMO

BACKGROUND: Outcome trials in patients with type 2 diabetes mellitus have demonstrated reduced hospitalizations for heart failure (HF) with sodium-glucose co-transporter-2 inhibitors. However, few of these patients had HF, and those that did were not well-characterized. Thus, the effects of sodium-glucose co-transporter-2 inhibitors in patients with established HF with reduced ejection fraction, including those with and without type 2 diabetes mellitus, remain unknown. METHODS: DEFINE-HF (Dapagliflozin Effects on Biomarkers, Symptoms and Functional Status in Patients with HF with Reduced Ejection Fraction) was an investigator-initiated, multi-center, randomized controlled trial of HF patients with left ventricular ejection fraction ≤40%, New York Heart Association (NYHA) class II-III, estimated glomerular filtration rate ≥30 mL/min/1.73m2, and elevated natriuretic peptides. In total, 263 patients were randomized to dapagliflozin 10 mg daily or placebo for 12 weeks. Dual primary outcomes were (1) mean NT-proBNP (N-terminal pro b-type natriuretic peptide) and (2) proportion of patients with ≥5-point increase in HF disease-specific health status on the Kansas City Cardiomyopathy Questionnaire overall summary score, or a ≥20% decrease in NT-proBNP. RESULTS: Patient characteristics reflected stable, chronic HF with reduced ejection fraction with high use of optimal medical therapy. There was no significant difference in average 6- and 12-week adjusted NT-proBNP with dapagliflozin versus placebo (1133 pg/dL (95% CI 1036-1238) vs 1191 pg/dL (95% CI 1089-1304), P=0.43). For the second dual-primary outcome of a meaningful improvement in Kansas City Cardiomyopathy Questionnaire overall summary score or NT-proBNP, 61.5% of dapagliflozin-treated patients met this end point versus 50.4% with placebo (adjusted OR 1.8, 95% CI 1.03-3.06, nominal P=0.039). This was attributable to both higher proportions of patients with ≥5-point improvement in Kansas City Cardiomyopathy Questionnaire overall summary score (42.9 vs 32.5%, adjusted OR 1.73, 95% CI 0.98-3.05), and ≥20% reduction in NT-proBNP (44.0 vs 29.4%, adjusted OR 1.9, 95% CI 1.1-3.3) by 12 weeks. Results were consistent among patients with or without type 2 diabetes mellitus, and other prespecified subgroups (all P values for interaction=NS). CONCLUSIONS: In patients with heart failure and reduced ejection fraction, use of dapagliflozin over 12 weeks did not affect mean NT-proBNP but increased the proportion of patients experiencing clinically meaningful improvements in HF-related health status or natriuretic peptides. Benefits of dapagliflozin on clinically meaningful HF measures appear to extend to patients without type 2 diabetes mellitus. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02653482.

2.
Cell Rep ; 28(12): 3047-3060.e7, 2019 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-31533030

RESUMO

CXCR5 is a key marker of follicular helper T (TFH) cells. Using primary lymph nodes (LNs) from HIV-infected patients, we identified a population of CXCR5- CD4+ T cells with TFH-cell-like features. This CXCR5- subset becomes expanded in severe HIV infection and is characterized by the upregulation of activation markers and high PD-1 and ICOS surface expression. Integrated analyses on the phenotypic heterogeneity, functional capacity, T cell receptor (TCR) repertoire, transcriptional profile, and epigenetic state of CXCR5-PD-1+ICOS+ T cells revealed a shared clonal relationship with TFH cells. CXCR5-PD-1+ICOS+ T cells retained a poised state for CXCR5 expression and exhibited a migratory transcriptional program. TCR sequence overlap revealed a contribution of LN-derived CXCR5-PD-1+ICOS+ T cells to circulating CXCR5- CD4+ T cells with B cell help function. These data link LN pathology to circulating T cells and expand the current understanding on the diversity of T cells that regulate B cell responses during chronic inflammation.

3.
J Am Geriatr Soc ; 67(8): 1730-1736, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31220334

RESUMO

OBJECTIVES: To describe the Bundled Hospital Elder Life Program (HELP and HELP in Home Care), an adaptation of HELP, and examine the association of 30-day all-cause unplanned hospital readmission risk among older adults discharged to home care with and without Bundled HELP. DESIGN: Matched case-control study. SETTING: Two medical-surgical units within two midwestern rural hospitals and patient homes (home health). PARTICIPANTS: Hospitalized patients, aged 65 years and older, discharged to home healthcare with and without Bundled HELP exposure between January 1, 2015, and September 30, 2017. Each case (Bundled HELP, n = 148) was matched to a control (non-Bundled HELP, n = 148) on Charlson Comorbidity Index, primary hospital diagnosis of orthopedic condition or injury, and cardiovascular disease using propensity score matching. MEASUREMENTS: The primary study outcome was 30-day all-cause unplanned hospital readmission. Additional outcomes measured were 30-day emergency department (ED) visit, hospital length of stay (LOS), and total number of skilled home care visits. RESULTS: Fewer cases (16.8%) than controls (28.4%) had a 30-day all-cause unplanned hospital readmission. The fully adjusted model showed significantly lower risk of 30-day hospital readmission for case (Bundled HELP) patients (0.41; 95% confidence interval = 0.22-0.77; P < .01). The difference between case (10.8%) and control (15.5%) 30-day ED visit was not significant (P = .23). A lower LOS for the case group was shown (P < .01), while the number of skilled home care visits was not significantly different between groups (P = .28). CONCLUSION: HELP protocol implementation during a patient's hospital stay and as a continued component of home care among older adults at risk for cognitive and/or functional decline appears to be associated with favorable outcomes. Our initial evaluation supports continued study of the Bundled HELP. Further research is needed to confirm the initial findings and to evaluate the impact of the adapted model on functional outcomes and delirium incidence in the home. J Am Geriatr Soc 67:1730-1736, 2019.

4.
Innov Aging ; 2(2): igy025, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30480142

RESUMO

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

5.
Clin Neuropsychol ; 32(7): 1193-1225, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30396329

RESUMO

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.


Assuntos
Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/psicologia , Testes Neuropsicológicos , Saúde da População , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/epidemiologia , Colorado , Congressos como Assunto/tendências , Assistência à Saúde/métodos , Demência/diagnóstico , Demência/epidemiologia , Demência/psicologia , Feminino , Humanos , Masculino
7.
Prim Care ; 45(3): 433-454, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30115333

RESUMO

The primary care provider will commonly see skin and soft tissue infections in the outpatient setting. Skin and soft tissue infections range from the uncomplicated impetigo to the potentially lethal necrotizing fasciitis. This article reviews these infections based on their underlying etiology: bacterial, fungal, and viral causes. This article discusses the etiology, presentation, evaluation, and management of impetigo, bullous impetigo, erysipelas, cellulitis, periorbital cellulitis, orbital cellulitis, folliculitis, furuncles, carbuncles, abscess, necrotizing fasciitis, sporotrichosis, tinea corporis, tinea pedis, tinea capitis, Herpes Simplex Virus, zoster, molluscum contagiosum, and warts.


Assuntos
Dermatopatias Infecciosas/diagnóstico , Dermatomicoses/diagnóstico , Dermatomicoses/tratamento farmacológico , Dermatomicoses/microbiologia , Dermatomicoses/patologia , Humanos , Pele/microbiologia , Pele/patologia , Pele/virologia , Dermatopatias Bacterianas/diagnóstico , Dermatopatias Bacterianas/tratamento farmacológico , Dermatopatias Bacterianas/microbiologia , Dermatopatias Bacterianas/patologia , Dermatopatias Infecciosas/tratamento farmacológico , Dermatopatias Infecciosas/microbiologia , Dermatopatias Infecciosas/patologia
8.
Prim Care ; 45(3): xv-xvi, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30115344
9.
Clin Geriatr Med ; 34(3): 369-386, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30031422

RESUMO

In the emergency department (ED), frailty represents the vulnerability of an individual because of their underlying health status. An older patient can be identified as frail by using a frailty index, the Clinical Frailty Scale, a frailty phenotype, or a screening measure such as the Identification of Seniors at Risk (ISAR). In the ED, the frail older person should have an interdisciplinary assessment, a thoughtful review of their medications, a screen for other geriatric syndromes, and a care plan that addresses the individual's needs, includes the patient's goals and preferences, and follows the patient beyond the ED.


Assuntos
Serviço Hospitalar de Emergência , Fragilidade , Avaliação Geriátrica/métodos , Medição de Risco/métodos , Idoso , Idoso Fragilizado , Fragilidade/diagnóstico , Fragilidade/terapia , Humanos , Comunicação Interdisciplinar , Administração dos Cuidados ao Paciente/métodos , Populações Vulneráveis
11.
J Am Geriatr Soc ; 66(7): 1404-1408, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29963688

RESUMO

Small fellowship programs face challenges in providing learners with sufficiently diverse experiences and patient populations. The Fellows Most Difficult Case Conference is designed to broaden geriatric medicine fellows' exposure to cases and to faculty and fellows from around the country through a monthly telephone conference. We describe this innovative approach to a national monthly complex case conference that fellows from almost one-third of geriatrics fellowship programs attend, including its value to geriatric fellows and faculty and administrative costs. Once per month, a fellow presents a case, a moderator leads the discussion, and 2 faculty members provide teaching points during the 60-minute session. Participants rated the conference's value using an 11-item on-line survey followed by a debriefing held during a regularly scheduled 2017 monthly conference. Thirty-six percent of eligible participants responded to the survey (67/186), with 75% of respondents reporting that they applied knowledge gained from the conferences to their patient care at least 1 or 2 times per month and 41% that they applied it at least once per week. Participants appreciated the inclusion of multiple programs, the duration of the conference, and the interactive approach. Our administration time was less than 5 hours per month, plus a few additional hours annually to create the academic year schedule. We believe that this national case conference, the first of its kind in the country, involving almost one-third of geriatrics fellowship programs, is an innovative and valuable way for fellows to explore complex cases and variations in regional perspectives and to connect with additional colleagues.


Assuntos
Educação de Pós-Graduação em Medicina/organização & administração , Bolsas de Estudo/organização & administração , Geriatria/educação , Competência Profissional , Congressos como Assunto , Geriatria/organização & administração , Humanos , Estados Unidos
12.
FP Essent ; 466: 11-13, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29528204

RESUMO

Functional gastrointestinal disorders (FGIDs) are among the most challenging conditions to diagnose and manage. FGIDs are a heterogeneous group of conditions with varying and sometimes vague symptomatology. The Rome IV classification is the most comprehensive resource on FGIDs. FGIDs are common and are associated with significant social and economic burdens. The patient perspective includes anxiety, emotional distress, and mistrust of health care. Psychological stressors and concomitant psychiatric illness are common but not always present. Clinician understanding of these disorders is limited, and there are many barriers to adequate care. A strong clinician-patient relationship is essential. Management includes education, reassurance, dietary modification, pharmacotherapy, and psychological interventions.


Assuntos
Gastroenteropatias/diagnóstico , Gastroenteropatias/terapia , Educação de Pacientes como Assunto , Relações Médico-Paciente , Adulto , Feminino , Gastroenteropatias/classificação , Gastroenteropatias/epidemiologia , Humanos
13.
FP Essent ; 466: 14-20, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29528205

RESUMO

Functional upper gastrointestinal disorders are common and cause significant patient distress and health care cost. These disorders typically are classified as either esophageal or gastroduodenal. Functional esophageal disorders include functional heartburn, reflux hypersensitivity, and functional dysphagia. Functional gastroduodenal disorders include functional dyspepsia and cyclic vomiting syndrome. Cyclic vomiting syndrome should be suspected in any patient with multiple episodes of vomiting with no apparent cause that completely resolve between episodes. Evaluation often is dependent on clinical findings. Therefore, a thorough history and physical examination are required to rule out any structural organic etiologies of red flag signs and symptoms. Diagnosis is ultimately based on Rome IV criteria. Education about the condition and lifestyle modifications is an ideal initial management for all functional upper gastrointestinal disorders. When this strategy alone is ineffective, behavioral therapy and pharmacotherapy can be useful. For patients with functional dyspepsia, acid suppression therapy and Helicobacter pylori eradication may be effective for improving long-term symptomatology. For patients who do not benefit from initial medical treatment, antidepressants and bismuth may be useful.


Assuntos
Transtornos de Deglutição/diagnóstico , Dispepsia/terapia , Azia/diagnóstico , Azia/terapia , Vômito/terapia , Adulto , Transtornos de Deglutição/etiologia , Transtornos de Deglutição/terapia , Dispepsia/diagnóstico , Dispepsia/etiologia , Feminino , Azia/etiologia , Humanos , Pessoa de Meia-Idade , Vômito/diagnóstico , Vômito/etiologia , Adulto Jovem
14.
FP Essent ; 466: 21-28, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29528206

RESUMO

Functional lower gastrointestinal disorders include irritable bowel syndrome (IBS), functional constipation, functional fecal incontinence, and functional anorectal pain. These disorders are common and have significant medical and social effects. They also can be challenging to manage. Patients with mild symptoms may benefit from lifestyle modification. IBS is classified into two subtypes: diarrhea-predominant and constipation-predominant. Depending on the IBS subtype and its likely etiology, patients may benefit from treatment with antispasmodics, antidepressants, guanylate cyclase-C agonists, chloride channel activators, antidiarrheal agents, probiotics, and/or antibiotics. Functional constipation responds to many of the same treatments as constipation-predominant IBS, which include guanylate cyclase-C agonists and chloride channel activators. The management of functional fecal incontinence includes behavioral therapy, relief of constipation (disimpaction, bulking agents), and antidiarrheal drugs. Functional anorectal pain management has not been well studied, but patient symptoms may improve with physical therapy, antispasmodics, nerve block, or onabotulinumtoxinA injection.


Assuntos
Constipação Intestinal/terapia , Síndrome do Intestino Irritável/diagnóstico , Síndrome do Intestino Irritável/tratamento farmacológico , Dor/etiologia , Adulto , Doenças do Ânus/complicações , Constipação Intestinal/diagnóstico , Constipação Intestinal/etiologia , Diarreia/etiologia , Incontinência Fecal/diagnóstico , Incontinência Fecal/terapia , Feminino , Humanos , Síndrome do Intestino Irritável/complicações , Síndrome do Intestino Irritável/terapia , Músculo Liso , Dor/diagnóstico , Manejo da Dor , Doenças Retais/complicações , Espasmo/complicações
15.
FP Essent ; 466: 29-35, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29528207

RESUMO

Functional gastrointestinal disorders (FGIDs) are common among children and cause tremendous distress for patients and families. Family physicians should know how to diagnose and manage some of the more common childhood FGIDs. These include infant regurgitation, infant colic, infant dyschezia, cyclic vomiting syndrome, functional nausea and vomiting, functional diarrhea and constipation, abdominal migraine, and nonspecific functional abdominal pain. Diagnosis requires a thorough history and physical examination to rule out red flag signs and symptoms for structural or organic etiologies. Rome IV criteria can help establish a specific diagnosis so that clinicians can select a therapeutic approach and share prognosis with the patient and family. In general, FGID management requires a biopsychosocial approach. This includes symptom management with drugs, where applicable, and establishing a therapeutic relationship with the child and family to relieve distress and dysfunction that may be caused by or cause the FGID. Behavioral therapies such as direct behavioral therapy for younger children and cognitive behavioral therapy for older children are helpful for most FGIDs. More recent approaches include use of probiotics and drugs. Probiotics, for example, can help alleviate symptoms of infant colic in exclusively breastfed infants.


Assuntos
Cólica/terapia , Diarreia/terapia , Refluxo Laringofaríngeo/terapia , Vômito/terapia , Dor Abdominal/diagnóstico , Dor Abdominal/terapia , Criança , Cólica/diagnóstico , Constipação Intestinal/diagnóstico , Constipação Intestinal/terapia , Diarreia/etiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/terapia , Náusea/etiologia , Náusea/terapia , Vômito/diagnóstico , Vômito/etiologia
16.
J Fam Pract ; 67(1): 10-16, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29309469

RESUMO

There is evidence to support the use of capsaicin to relieve osteoarthritis and postherpetic neuralgia and support for green tea to serve as a lipid-lowering agent and help treat diabetes. Similarly, researchers have found that peppermint may be of value in the management of irritable bowel syndrome. We also review the literature on butterbur for migraine headaches, but serious safety issues exist.


Assuntos
Camellia sinensis , Capsaicina/uso terapêutico , Mentha , Petasites , Fitoterapia , Chá , Humanos
17.
J Fam Pract ; 67(1): E1-E9, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29309470

RESUMO

In part one of this series, we discussed the studies that have been done on capsaicin, butterbur, green tea, and peppermint. In this installment, we outline the research on 5 additional remedies: turmeric/curcumin, which may be of benefit in ulcerative colitis; chamomile, which appears to offer relief to patients with anxiety; rosemary, which may help treat alopecia; as well as coffee and cocoa, which may have some cardiovascular benefits.


Assuntos
Camomila , Curcuma , Fitoterapia , Rosmarinus , Cafeína/uso terapêutico , Estimulantes do Sistema Nervoso Central/uso terapêutico , Chocolate , Café , Humanos
18.
J Vasc Surg Venous Lymphat Disord ; 6(2): 202-211, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29292119

RESUMO

BACKGROUND: Reflux in the ovarian veins, with or without an obstructive venous outflow component, is reported to be the primary cause of pelvic venous insufficiency (PVI). The degree to which venous outflow obstruction plays a role in PVI is currently ill-defined. METHODS: We retrospectively reviewed the charts of 227 women with PVI who presented to the Center for Vascular Medicine from January 2012 to September 2015. Assessments and interventions consisted of an evaluation for other causes of chronic pelvic pain by a gynecologist; preintervention and postintervention visual analog scale (VAS) pain score; complete venous duplex ultrasound examination; and Clinical, Etiology, Anatomy, and Pathophysiology classification. All patients underwent diagnostic venography of their pelvic and left ovarian veins as well as intravascular ultrasound of their iliac veins. Patients were treated in one of six ways: ovarian vein embolization (OVE) alone (chemical ± coils), OVE with staged iliac vein stenting, OVE with simultaneous iliac vein stenting, iliac vein stenting alone, OVE with venoplasty, and venoplasty alone. RESULTS: Of the 227 women treated, the average age and number of pregnancies was 46.4 ± 10.4 years and 3.36 ± 1.99, respectively. Treatment distribution was the following: OVE, n = 39; OVE with staged stenting, n = 94; OVE with simultaneous stenting, n = 33; stenting alone, n = 50; OVE with venoplasty, n = 8; and venoplasty alone, n = 3. Seven patients in the OVE and stenting groups (staged) and one patient in the OVE + venoplasty group required a second embolization of the left ovarian vein. Eighty percent (181/227) of patients demonstrated an iliac stenosis >50% by intravascular ultrasound. Average VAS scores for the entire cohort before and after intervention were 8.45 ± 1.11 and 1.86 ± 1.61 (P ≤ .001). In the staged group, only 9 of 94 patients reported a decrease in the VAS score with OVE alone. VAS score decreased from 8.6 ± 0.89 before OVE to 7.97 ± 2.10 after OVE. After the planned staged stenting, VAS score decreased to 1.33 ± 2.33 (P ≤ .001). Similarly, in the simultaneous group, preintervention scores were 8.63 ± 1.07 and decreased to 2.36 ± 2.67 after OVE + stenting (P ≤ .001). CONCLUSIONS: The majority of patients in our series (80%) demonstrated a significant iliac vein stenosis. These observations indicate that the incidence of iliac vein outflow obstruction in PVI is greater than previously reported. In patients with combined ovarian vein reflux and iliac vein outflow obstruction, our data suggest that pelvic venous outflow lesions should be treated first and that ovarian vein reflux should be treated only if symptoms persist. In women with an outflow lesion, ovarian vein reflux, and a large pelvic reservoir, we recommend simultaneous treatment.


Assuntos
Veia Ilíaca , Ovário/irrigação sanguínea , Doenças Vasculares Periféricas/fisiopatologia , Insuficiência Venosa/fisiopatologia , Adulto , Dor Crônica/diagnóstico , Dor Crônica/etiologia , Constrição Patológica , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Veia Ilíaca/diagnóstico por imagem , Veia Ilíaca/fisiopatologia , Incidência , Pessoa de Meia-Idade , Medição da Dor , Dor Pélvica/diagnóstico , Dor Pélvica/etiologia , Doenças Vasculares Periféricas/diagnóstico por imagem , Doenças Vasculares Periféricas/epidemiologia , Doenças Vasculares Periféricas/terapia , Flebografia , Gravidez , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Stents , Resultado do Tratamento , Ultrassonografia de Intervenção , Estados Unidos/epidemiologia , Insuficiência Venosa/diagnóstico por imagem , Insuficiência Venosa/epidemiologia , Insuficiência Venosa/terapia
20.
J Am Geriatr Soc ; 65(4): 674-679, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28306149

RESUMO

Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.


Assuntos
Geriatria , Medicare/economia , Medicare/legislação & jurisprudência , Mecanismo de Reembolso/economia , Mecanismo de Reembolso/legislação & jurisprudência , Humanos , Médicos , Estados Unidos
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